PSA detected after salvage radiation and prostectomy

@aprapr My second opinion GU is recommending allowing PSA to rise to 2, not .2 stating he could find if I BCR again. Chairman of GU Dept. at a Comprehensive Cancer Center Hospital. This sets some on edge within the blog. There were discussions among this group about that level with the context being where do they treat if you have already had salvage in an area that couldn't be seen on a PSMA PET once hitting .2. I think the Prostate bed is the initial target when there isn't a "light up." I can't imagine going after that area again without solid information due to the side effects I am still experiencing 10 months post radiation. If the PSMA Pet doesn't show anything at this point I would want some additional testing.

@chippydoo
When you get salvage radiation, they give you the maximum radiation for that area for life. They can’t go back into that area with radiation. They can use SBRT to zap metastasis in other areas.

A few doctors have recommended waiting until the PSMA pet scan shows something. Dr’s Kwon and Scholz Seem to believe in that. They don’t wait for it to get to two however, if your PSA hits one, the PSMA PET scan works quite well.

@jeffmarc I didn't realize that was a lifetime dose. Perhaps that's why the side effects drag on. Thanks for the info.

Ah, yes, the prostate specific (ultrasensitive) anxiety test....

With thè introduction of the USPSA test, we ask ourselves, just because we can measure to two or three decimal points, does it necessitate action on our part? It can foretell a treatment decision, but the question is when?

My surgery too was in 2014, "Back in the day" my urologist tested only to a single decimal point so my labs for the first 12 months came back at < .1, "undetectable." Today, would the USPSA tell a different story and if so, would that have changed the treatment decision?

I guess the question is. with USPSA, what, if anything to do, when, with what, for how long...?

From 2014-to 2023 is a long time and a data point that can guide any treatment decision. Other data points include the pathology report, the Decipher test, PSA results which can be used to calculate PSA doubling and velocity times.

As others have suggested, there may be other scans which may show where the activity is.

A question for you, your husband and his medical team may be what clinical data constitutes sufficiency to act? Ig data from imaging is part of the decision process then you may face another decision, how far to let the PSA rise to increase the statistical probability of a scan showing activity? Below .5 a PSMA PET has generally a 1/4 chance, between .5-1.0 it doubles and intuitively, increasers above that. A question to discuss with your medical team may be the risk benefit of letting his PSA rise to whatever point you decide to image. For my medical team and I, we are comfortable with .5-1.0, then image and go from there.

I mentioned PSADT and PSAV because combined with his time to BCR after surgery, GS, GG, Decipher score, a choice may be to just continue to actively monitor:

PSADT
>12 months continue actively monitoring
6-12 months - the grey zone, use other clinical data
< 6 months treatment likely necessary

Surprised but not really that his SRT did not include whole pelvic lymph node and short-term systemic therapy, 6-18 months, but as the old adage goes, water under the bridge...The question is front of you now is what to do?

If you want to be proactive and aggressive, one treatment decision could be whole pelvic lymph node radiation combined with systemic therapy for a defined period, 6-18 months. That systemic therapy could include ADT + ARI. That decision comes with costs, the quality of life, financial, time to go to appointments...

Alternatively, you could do "nothing." Actually, that's a misnomer. You could continue to actively monitor, have criteria about when to image, then decide.

Were I you, what would I do? The latter. The clinical data you describe from my foxhole does not require a treatment decision now.

As always, remember, I am not a medical professional, not trained, educated, licensed or board certified.

Kevin

@kujhawk1978 thank you Kevin. You certainly have given me some great information to share and discuss with our medical team. Truly appreciate you responding.

Sorry to hear all this. I’ve been a somewhat of a similar journey and have some nuggets of experience worth sharing.

First, a question: You said that your husband’s PSA was undetectable on the first test following radiation therapy in May 2025. Was this a standard test where the lower limit of detection is 0.1? If so, the 0.11 result is barely above detection and could be due to lab variation. I would get a retest in that situation.

I was diagnosed with a local recurrence this past June. I had a RARP in 2015 (also Gleason 7) and went ten years with undetectable PSA. In June my PSA rose to 0.11 (Quest Labs). A few days later, I repeated the test because of the potential for lab variation. Second test yielded 0.12 (also Quest). A DRE revealed a small nodule in my prostate bed, so a PSMA PET scan was ordered, despite my low PSA.

The nodule lit up like a Christmas tree on the PET scan (SUV max of 13.3). Conventional wisdom in the medical community is that PSMA PET scans are very unlikely to show activity at PSA below 0.5. I completely defied those odds and to this date no medical doctor I’ve asked (PCP, urologist, oncologist) can explain the discrepancy between my low PSA and the intense PSMA PET scan results. Object lesson: don’t assume that a PSMA PET scan will come up blank at low PSA values.

Three months after my initial diagnosis, I retested my PSA days before starting 8 weeks of IMRT. The standard test at Quest once again came back at 011. I also did an ultra sensitive test at Labcorp on the same day (samples were collected about 20 minutes apart). That came back at 0.094—below detection for a standard test! But in essence, you could say my PSA was 0.1 and had not changed at all in 3 months.

I was quite concerned and surprised when my PSA registered 0.11 in June. My urologist was more dismissive initially but came around fast when the second PSA test a few days later came back at 0.12 and then the nodule was detected. At first he didn’t want to repeat the PSA test for another three months, so I went to my PCP who was absolutely proactive about a repeat test to rule out lab variance.. I would have been willing to pay OOP otherwise. That 0.11 result was just so barely over the limit of detection and within the range of lab variance. I don’t like making assumptions when there are ways to avoid doing that.

Anyway, test and retest, and don’t let conventional wisdom regarding PSA and PSMA PET scans keep your husband from getting that scan.

A lot of docs (and patients) seem to shy away from DREs these days. It was a DRE that ultimately lead to my diagnosis of a recurrence, not PSA. I’ve been poked and prodded so many times and in so many ways that I am way past any discomfort about that. A DRE ay well have saved my life this last time.

Best wishes going forward. This recurrence stuff is a whole different ballgame than the first go round. Keep us updated please.

@melvinw to your first question, his May PSA was < .10, Which I believe is standard test. All his PSA tests have been done at Mayo Jax. Next Retest of PSA will be last week in Jan along with PET CT, skull to thigh, PSMA scan. They will also be doing a comprehensive blood panel, including his testosterone level, which has not previously been done. I don’t believe he has had a DRE since he was first diagnosed in 2014. Thank you for sharing your experience. It certainly is helpful and I have a copy of your comments in my file for discussions with our medical team. Best of luck to you. I will provide an update when I have one.

@aprapr Sounds like you have a good plan. I know your anxiety all too well, but also a PSA of 0.11 means you are on it as early as can be, if it is a BCR.

Dr. Patrick Walsh’s ‘Surviving Prostate Cancer’ book has some very informative tables in Chapter 12 regarding metastasis risk and odds of not dying from prostate when PSA rises after primary treatment. In your husband's case, the Gleason 7 score, the long time to recurrence (>3 years), and PSA doubling time greater than 9 months are all heavily in his favor. For example, with Gleason score < 8, recurrence >3 years after surgery and PSA doubling time of 9 to 14.9 months, the odds of not dying from PCa are 95% according to those tables. And those tables use data from men who did not benefit from all the technological advances of the last 5-10 years.

May the Odds Be With You and Your Hubby!

Ya know...one thing I want to throw out here that I have yet to read here in this Blog is:
How does the doctor know that the remaining prostate tissue producing PSA after prostatectomy and, in this case, after Salvage (or Adjuvant) radiation, is in fact "cancerous" prostate tissue? Ya...has anyone thought that, because a lot of our cancerous prostate also had "healthy/non-cancerous tissue", that "maybe" the source of the PSA that becomes detectable after prostatectomy, and perhaps after radiation, may just be coming from healthy, non-cancerous prostate trying to grow back?
While any follow-up PET Scan or other technology can't detect minute numbers of prostate cells that have taken-up Gallium-68 radioactive tracer, we have to consider the fact that maybe part of that "lack of Gallium-68 uptake" is because the prostate tissue growing and producing PSA, is in fact "healthy" and "non-cancerous" that would not see Gallium-68 uptake.
Our urologists and radiation oncologists seem to defer to the belief that "any detectable and increasing quantities of PSA that occur post-prostatectomy and post-radiation, 'must be' from 'cancerous' surgical margin tissue from what was the cancerous part of the prostate." They assume that when there are surgical margins with the cancerous tissue remaining, that there is no healthy/non-cancerous prostate tissue that also remained in us. They assume that by removing the entire prostate, that they took "all" of the healthy, non-cancerous tissue, and all that remains with surgical margins or as tissue in general, "must be" cancerous tissue. And it is an easy extension from there...a conclusion they take to the bank...that any and all PSA detectable after prostatectomy and radiation "must be" from cancerous tissue that is growing. I am a perfect example: Of my 12-core biopsy samples, three were negative...no cancer detected. If and when my PSA starts to rise in the future, is it possible that some of that health tissue was left in my body, and that it is those cells making the PSA?
I guess in the long run, we are better off for our radiologists to err on the side of caution: "it's likely cancerous tissue making that PSA", than to wait perhaps years to when a PET Scan might be worth repeating with enough tissue to take up the Gallium-68 for detection. But then the question also becomes: Is a "negative" PET Scan a reflection of normal healthy, non-cancerous tissue growing and producing the PSA, or...is it "PET Scan-undetectable" cancerous tissue producing the PSA? They would be lying if they told they can tell the difference, when in fact, they don't know, and can't know.

@rlpostrp
When they take out a prostate, they remove the whole thing. Your idea that they leave some in and that’s what causes the PSA to rise is not factually based. If they don’t get clean margins then cancer that has spread outside the prostate to tissue that is not part of the prostate.

That’s why, when the PSA starts rising, they know it’s not leftover prostate tissue.